What is the recommended treatment for acute otitis media?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) is the first-line antibiotic treatment for most children with acute otitis media, though observation without immediate antibiotics is appropriate for selected children ≥6 months with non-severe symptoms and reliable follow-up. 1, 2

Initial Management Decision: Antibiotics vs. Observation

The decision to prescribe antibiotics immediately versus observation depends on three key factors: age, symptom severity, and laterality (unilateral vs. bilateral):

Immediate antibiotics are indicated for:

• All children <6 months of age 1, 2
• Children 6-23 months with severe AOM (moderate-to-severe otalgia >48 hours or temperature ≥39°C/102.2°F) 1, 2
• Children 6-23 months with bilateral non-severe AOM 1, 2
• Children ≥24 months with severe AOM 1, 2
• Any age when follow-up cannot be ensured 1

Observation without immediate antibiotics is appropriate for:

• Children 6-23 months with non-severe unilateral AOM 1, 2
• Children ≥24 months with non-severe AOM 1, 2

When observation is chosen, a mechanism must be in place to ensure follow-up within 48-72 hours, with immediate antibiotic initiation if symptoms worsen or fail to improve. 1, 2

Pain Management: The First Priority

Pain control must be addressed immediately in every patient, regardless of whether antibiotics are prescribed. 1, 2 Analgesics such as acetaminophen or ibuprofen should be initiated within the first 24 hours and continued as long as needed. 3, 1, 2 This is critical because antibiotic therapy does not provide symptomatic relief in the first 24 hours, and even after 3-7 days, 30% of children younger than 2 years may have persistent pain or fever. 3

First-Line Antibiotic Selection

Amoxicillin at 80-90 mg/kg/day divided into 2 doses is the recommended first-line treatment due to its effectiveness against common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), safety profile, low cost, acceptable taste, and narrow microbiologic spectrum. 1, 2

Use amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) as first-line instead when:

• The patient received amoxicillin in the previous 30 days 1, 2
• Concurrent purulent conjunctivitis is present 1, 2
• Coverage for beta-lactamase-producing organisms (H. influenzae, M. catarrhalis) is needed 1

Penicillin Allergy Alternatives

For penicillin-allergic patients, alternative antibiotics include:

• Cefdinir (14 mg/kg/day in 1-2 doses) 1
• Cefuroxime (30 mg/kg/day in 2 divided doses) 1
• Cefpodoxime (10 mg/kg/day in 2 divided doses) 1
• Ceftriaxone (50 mg IM or IV per day for 1-3 days) 1

Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these cephalosporins generally safe for patients with non-severe penicillin allergy. 1

Azithromycin can be used at 30 mg/kg as a single dose or 10 mg/kg once daily for 3 days for acute otitis media in pediatric patients, though it is not considered first-line. 4

Treatment Duration

Treatment duration varies by age and severity:

• Children <2 years: 10-day course 1
• Children 2-5 years with mild-to-moderate AOM: 7-day course 1
• Children ≥6 years with mild-to-moderate symptoms: 5-7 day course 1

Management of Treatment Failure

If symptoms worsen or fail to improve within 48-72 hours:

• Reassess to confirm AOM diagnosis and exclude other causes 1, 2
• If initially managed with observation, begin antibiotics 1, 2
• If initially treated with amoxicillin, switch to amoxicillin-clavulanate 1, 2
• If failing amoxicillin-clavulanate, consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days, with 3-day regimen superior to 1-day) 1

For children with multiple treatment failures, tympanocentesis with culture and susceptibility testing should be considered to guide antibiotic selection. 1

Post-Treatment Follow-Up

After successful antibiotic treatment, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 40% at 1 month and 10-25% at 3 months. 1 This persistent effusion without acute symptoms is defined as otitis media with effusion (OME) and requires monitoring but not antibiotics. 1

Critical Pitfalls to Avoid

Antibiotics do not eliminate the risk of complications: 33-81% of children who develop acute mastoiditis had received prior antibiotics for AOM. 1 This underscores that antibiotics reduce but do not eliminate complication risk.

Avoid ototoxic topical preparations when tympanic membrane integrity is uncertain, particularly in cases with perforation. 1, 5

Do not use corticosteroids (including prednisone) routinely in AOM treatment, as current evidence does not support their effectiveness. 1

Prevention Strategies

Risk reduction strategies include:

• Breastfeeding for at least 6 months 1, 2
• Reducing or eliminating pacifier use after 6 months of age 1, 2
• Avoiding supine bottle feeding 1, 2
• Minimizing daycare attendance patterns when possible 1, 2
• Eliminating tobacco smoke exposure 1, 2
• Pneumococcal conjugate vaccine (PCV-13) 1, 2
• Annual influenza vaccination 1, 2

Long-term prophylactic antibiotics are discouraged for recurrent AOM. 1 For children with recurrent infections despite these measures, tympanostomy tube placement should be considered, with failure rates of 21% for tubes alone and 16% for tubes with adenoidectomy. 1